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Home , Alcoholics Anonymous, Physical dependence

and Drug Abuse and Dependence

Chapter 5

ALCOHOL AND DRUG ABUSE AND DEPENDENCE

HENRY K. WATANABE, M.D.,* PAUL T. HARIG, PH.D.,† NICHOLAS L. ROCK, M.D.,‡ AND RONALD J. KOSHES, M.D.§

INTRODUCTION

HISTORY

DIAGNOSIS AND DEFINITIONS

DETERMINANTS OF

CURRENT THEORIES

IDENTIFICATION

TREATMENT

MANAGEMENT OF CLINICAL CONDITIONS

TREATMENT MODALITIES

PREVENTION AND CONTROL

OPERATIONAL CONSIDERATIONS

SUMMARY AND CONCLUSION

*Colonel, Medical Corps, U.S. Army; Medical Member Physical Evaluation Board, Walter Reed Army Medical Center; Guest Scientist, Department of Military , Walter Reed Army Institute of Research, Washington, D.C. 20307–5100 †Lieutenant Colonel, Medical Service Corps, U.S. Army; Director, Army Fitness Research Institute, Army War College, Carlisle Barracks, Pennsylvania 17013–5050 ‡Colonel (ret), Medical Corps, U.S. Army; Medical Director, The Rock Creek Foundation, Silver Spring, Maryland 20910–4457 §Medical Director, Adult Services Administration, Commission on Services, Department of Human Services, District of Columbia, Washington; Guest Scientist, Department of Military Psychiatry, Walter Reed Army Institute of Research, Washington, D.C.; Assistant Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland; President, Society of American Military Psychiatrists

61 Military Psychiatry: Preparing in Peace for War

INTRODUCTION

Among the numerous studies1,2,3 that have at- reported to have doubled every year from 1967 to tempted to explain why some occupational groups 1969.5 The return from Vietnam of thousands of claim a higher level of excessive alcohol consump- soldiers who had reportedly used raised tion, the common threads of stress and boredom are public anxiety over the possibility of a drug epi- found. It is not surprising that alcohol and sub- demic, and a congressional investigation confirmed stance abuse could become problems in a combat that overseas drug use was prevalent among U.S. environment because they are expedient pathways troops.4 Indeed, the Vietnam conflict was the first to stress management. American war in which drug and alcohol depen- The history of past wars demonstrates this. In the dency overshadowed combat stress reactions as a late 1960s and early 1970s, thousands of returning problem for military psychiatry. The large preva- soliers who had served in Vietnam and reportedly lence of drug abuse among troops in Vietnam had used narcotics there aroused public anxiety about unique political sensitivity for an administration the existence of a drug epidemic among U.S.troops.4 that had campaigned on a strong law and order Before the early 1970s, the military dealt with platform that tied drug use to rising crime rates. It serious substance abuse by administrative and le- also added fuel to opponents’ demands for immedi- gal means (discharge and punishment) although it ate troop withdrawals, which, in turn, was per- did not respond to every instance of substance ceived as a major political threat to the President’s abuse. The medical concerns were with treating Vietnamization program.6 serious medical complications. However, after 1970, In response, the administration created a drug Congress mandated a change from punitive mea- abuse office within the Federal Government, em- sures to treatment and rehabilitation. Since then, phasizing the prevention of drug abuse through improvements have resulted in providing a com- education and law-enforcement procedures focus- prehensive program based on command responsi- ing on detection. The day after the President de- bility with significant medical interface. Currently, clared a national counteroffensive against drug the basic policy in the military services is to keep a abuse, the U.S. Army in Vietnam began urine test- sustained effort to prevent substance abuse prob- ing for opiates for all soldiers completing their lems from occurring and to eliminate from the ser- tours. Detoxification, treatment, and rehabilitation vice those who cannot effectively be restored within were provided to those who were identified as a reasonable period. heroin abusers. Army regulations were soon modi- Substance abuse is not tolerated not only because fied to create an amnesty for those who voluntarily of its physiological effects on the abuser that would turned themselves in for treatment. This amnesty jeopardize mission requirements, but also because was a big step because it eliminated criminal conse- of its psychosocial implications in the unit. While a quences to treating individuals for problems with kind of cohesion can occur around the use of sub- narcotics. By November 1971, unannounced testing stances,1 substance abuse is definitely damaging to for and , as well as opiates, the good order and morale of the unit and interferes had commenced worldwide, and treatment programs with mission accomplishment. were being phased in throughout the world.7 The command structure has been charged with Recently, the epidemic of crack and use the responsibility for the alcohol and drug abuse in the civilian population has had parallel conse- program. The medical services are to offer consulta- quences in the military. Given the generally poor tion and technical supervision to individuals who rate of rehabilitation for these substances using work for the command and to provide specific and conventional treatments, the appearance of cocaine direct medical support for those with identified and crack on the military scene has resulted in problems. The purpose of this chapter is to assist significant manpower losses. Koshes and Shanahan8 medical personnel to achieve those command goals tracked the disposition of soldiers who tested posi- and objectives. tive for cocaine at a U.S. Army training post. All of The illegal use of drugs in civilian life and in the those who tested positive were dismissed from the military began to steadily increase after 1967, and service, many of whom were high-ranking enlisted illicit drug usage among military personnel was soldiers with many years of service.

62 Alcohol and Drug Abuse and Dependence

HISTORY

Pre-1971 During the Russo-Japanese War (1904–1906), the Russians identified three common types of Alcohol problems have existed in most of the “mental cases”: depressive syndrome, general armies throughout the world since historical records paresis, and alcohol .12 In the U.S. have been kept. Narcotic occurred during Army, from 1907–1917, admissions for alcohol the Civil War, World War I, World War II, the problems were 16 per 1,000 troops per annum.13 Korean conflict, and the Vietnam conflict, as well as During World War II, the alcohol admission with soldiers stationed in the continental United rate was 1.7 per 1,000 troops per annum, while States and overseas between and after the conflicts. the drug addiction rate was 0.1 per 1,000 Substance abuse has always been a potential occu- troops per annum. Combined, they made up pational hazard for medical personnel. As Farley 4.7% of all psychiatric diagnosis.14 Since World has observed, “Addiction to mood altering chemi- War II and until 1970, the pattern had remained cals ... is also a major problem in the medical profes- the same. However, in the 1970s drug abuse sion and particularly in the specialty of anesthesia.”9(p1) problems increased significantly in the armed This is in part because anesthesiologists have legal forces.2 (although controlled) access, in part because of the Attempts at solving the problems have been high stress and responsibilities of the profession, and historically poor. The Federal Anti-Narcotic Act in part because of a tendency for educated medical in 1914, the infamous act of 1919 to professionals to rationalize that they can self-admin- 1933, and the Federal Addiction Rehabilitation ister dangerous and addictive drugs safely. Act of 1966 were national attempts focusing The highly addictive properties of controlled mostly on the civilian community. medical substances such as the anesthetic fentanyl10 create unique problems for medical providers. The Post-1971 temptations of access and the dangers of self-ad- ministration of these drugs by military medical The subject of alcohol rehabilitation deserves personnel was evidenced in a near-epidemic of fen- special attention in this chapter because alcohol tanyl abuse among tri-service anesthesiologists and problems have traditionally been handled some- nurse anesthetists in the early 1980s. This abuse led what apart from other drugs of abuse, yet treat- to the special rehabilitation program for military ment policies were closely influenced by the personnel that is dictated by a quality assurance Department of Defense (DoD) drug counterof- regulation.11 This regulation linked substance abuse fensive. Initially, the recognition of the occupa- rehabilitation and medical quality assurance. The tional significance of and support purposes were to ensure that during rehabilitation, for its treatment was stimulated by several con- the practice credentials of drug-dependent health gressional initiatives, including the passage of professionals were restricted, and that their recov- important enabling legislation and the estab- ery was carefully monitored by medical authorities. lishment of the National Institute on Alcohol These policies reflected impaired health provider Abuse and Alcoholism to coordinate research statutes that were enacted by the state regulatory and public information. The first such law, the authorities. These statutes encourage rehabilitation Comprehensive and Alcohol- and full return to practice but also protect the con- ism Prevention, Treatment, and Rehabilitation sumer from possible harm during the provider’s Act,15 was sponsored by Senator Harold Hughes, recovery. a recovering alcoholic, and provided the During the 1800s, intoxication and country’s first comprehensive national policy tremens (DTs) from bromides resulted in many on alcoholism since the repeal of Prohibition. hospital admissions. intoxications were Among its provisions, it mandated treatment a common problem in the 1900s. The introduction of and rehabilitation for federal employees, pro- lysergic acid (LSD) in the 1950s resulted in newer hibited discrimination against alcoholics by problems related to psychosis. Since then, many hospitals that received federal funds, safe- more chemical agents have been utilized with re- guarded the confidentiality of treatment records, sultant problems for the military and civilian com- and encouraged worksite programs to identify munities.2 and treat drinking problems.

63 Military Psychiatry: Preparing in Peace for War

The year 1971 marked a turning point for mili- rehabilitation programs came to include a tary alcoholism programs when Senator Hughes commander’s approval and implied latitude to dis- introduced a companion law, Public Law 92–129, charge in lieu of treatment. that directed the Secretary of Defense to “identify, As the substance abuse policy was implemented treat and rehabilitate members of the armed forces and expanded, military and civilian personnel were who are drug or alcohol dependent.”3(p646) Conse- trained specifically for the Alcohol and Drug Abuse quently, military treatment for chronic alcohol prob- Prevention and Control Program (ADAPCP), and lems received increased visibility as it drew energy treatment facilities were created, expanded, and from incentives to combat the drug crisis that had evaluated. Total annual DoD outlays for drug and been festering during Vietnam. This visibility was alcohol prevention and control exceeded $228 mil- clearly a mixed blessing because DoD policies on lion in fiscal year 1987 and involved over 4,600 man drug abuse had begun to migrate away from the years of effort.3 These expenditures included the early focus on rehabilitation. costs (including personnel) for biochemical testing, In 1980, a comprehensive policy directive ex- education, treatment, training, and evaluation. In pressed the policy goal as follows: “To be free of the fiscal year 1988, for example, more than 47,000 of effects of alcohol and drug abuse; of the trafficking the 2.1 million active duty military personnel re- in illicit drugs by military and civilian members of ceived treatment for drug and alcohol problems. the Department of Defense; and of possession, use, Nearly 39,000 of these individuals were treated as sale, or promotion of drug abuse paraphernalia.”16 outpatients in 400 nonresidential facilities, while The policy clearly stated that drug and alcohol approximately 8,000 were treated as inpatients in 52 abuse were incompatible with the high standards of residential facilities.19 This made the DoD a major performance, military discipline, and readiness. The provider of inpatient alcoholism treatment and one emphasis on prevention and control resulted from of the world’s largest integrated occupational health the recognition that drug abuse and drug addiction programs targeted on substance abuse and chemi- were not synonymous,17 bolstered by the results of cal dependency. a worldwide survey18 that found drug use was most In 1986, DoD policies on drug and alcohol abuse prevalent among 18- to 25-year-olds who had not were placed in a broader context of health promo- developed the mature lifestyles that preclude abuse. tion that emphasized the value of healthy lifestyle Thereafter, the drug problem was reinterpreted to on personal readiness.16 By implication, alcohol exist more from a lack of discipline than from addic- abuse and drug abuse were characterized as un- tion. Accordingly, greater emphasis was placed on healthy behaviors that are incompatible with mili- prevention programs directed at all military per- tary service. Concurrently, an emphasis on deter- sonnel and on more punitive policies aimed at drug rence through routine urine drug screening and and alcohol abusers.19 stringent zero tolerance policies for those detected The reaction to the crash of a jet aircraft on the for drug use or convicted of has USS Nimitz in 1981 further emphasized the military’s achieved significant reductions in drug abuse in the problem with drugs by revealing the high incidence military.19 From 1982 to the present time, world- of marijuana use among those sailors who were wide surveys19 have confirmed the substantial re- killed in the crash.19 A stringent policy of zero duction in the use of illicit drugs and related medi- tolerance by military authority emerged from this cal and disciplinary problems. incident, with greater emphasis on random urine testing for drugs and severe disciplinary conse- Changing Trends, Unchanging Risks quences on users of illicit drugs. Along with the view that drug abuse reflected indiscipline more Progress in reducing alcohol abuse and alcohol- than addiction came an emphasis on command spon- ism among those in higher military ranks has not, sorship of the treatment system; that is, the alcohol however, been as pronounced as the counter-drug and drug prevention and control programs were program results. Bray and colleagues19 reported regarded as commanders’ programs. By placing standardized comparisons of prevalence of alcohol policy for these programs in line, rather than medi- and drug use among military personnel and civil- cal, channels the DoD emphasized that its primary ians with 1985 data. These analyses, which con- value was for manpower conservation and the ben- trolled for demographic differences, indicate that efits were the avoidance of heavy replacement costs drug use was significantly lower among military of skilled personnel. Thus, criteria for admission to personnel than for civilians, while heavy drinking

64 Alcohol and Drug Abuse and Dependence

was significantly higher. The analyses concluded explained by these factors. Moreover, two factors in that the zero tolerance policies for drug use in the combination—social pressure and inexpensive ac- military had been effective, but military life may be cess—explained over two-thirds of the variance by conducive to a greater likelihood of abusive levels themselves. Of these two factors, opportunity to of alcohol use among military personnel than among obtain alcoholic beverages inexpensively appeared civilians in general. to be the most critical. Fitting these characteristics Why the difference? Although there is a substan- into the military context, it is not difficult to specu- tial research literature20,21,22 that attempts to relate late that there might be relatively greater alcohol the occurrence of high rates of excessive drinking in consumption among this population. certain occupations as evidence for high-risk occu- Despite the military’s tendency to control drug pations, this relatively large body of literature is and alcohol problems through the same disciplin- based on many redundant citations and small ary pressures, a monolithic view of drinking prob- samples and is suspect on methodological grounds.20 lems that presupposes that excessive alcohol use is Therefore, it is difficult to explain the reported voluntary and reflects immaturity cannot reconcile differences in consumption between military and the phenomenon of late-onset alcoholism in adults civilian populations on job characteristics. Exami- who had been fairly indistinguishable from their nation of specific groups has yielded some general military peers. The glaring flaw is the inability to attributes that may explain some of the difference. explain the common phenomenon of the career sol- Trice and Roman,23 for example, found that un- dier or sailor whose drinking became severe and structured jobs without clear goals, jobs with re- disabling after 10 or 15 years of distinguished mili- mote supervision and frequent travel or isolation, tary service. It seems unlikely that any purported jobs that require drinking as a part of the work role, underlying factor of immaturity would apply to and jobs in competitive settings where drinking for these individuals because it would have been a relief is seen as justified have greater risk for drink- significant impediment to their career advancement ing problems. Plant21,24 did extensive research on and achievement. the brewing industry and suggested that an How, then, are such individuals affected? In early individual’s drinking pattern can be changed stages, their alcoholism may be eclipsed by a myriad through the influence of the general level of drink- of medical complications of excessive drinking. Then ing among work associates, availability of alcohol, later, because these career soldiers and sailors are the extent that coworkers cover up excesses, lax too successful to fit the stereotype of the occupa- supervision, and job stresses, including boredom. tionally dysfunctional alcoholic, their excessive con- Hingston et al25 did not find consistent levels of sumption is viewed as situational or voluntary, association between heavy drinking and workers’ opening them to the moral imperatives of a willful job perceptions, except that stress and boredom misconduct model. Thus, it is critical for the clini- were significantly related to amounts consumed. cian to appreciate that different populations may be They suggested, however, that stress and boredom represented in the common administrative net and could be the way workers rationalize excessive to refine an individual diagnosis that correctly sorts drinking, regardless of the actual nature of their the immature from the chemically dependent. work. As stated, Whitehead and Simpkins20 found Clearly, the DoD policy context—influenced as well many inconsistencies in work climate explanations by defense downsizing—impedes this objective for excessive drinking but were able to isolate eight somewhat. structural factors that were significantly related to Military personnel may not seek help because of alcohol problems in the workplace: (1) social pres- real or perceived threats to their careers. That per- sure to drink alcoholic beverages frequently, (2) ception, observes Bray et al,19 is not surprising in peer sanction of heavy drinking, (3) recruitment of view of the emphasis of disciplinary action for drug heavy drinkers in the occupational field, (4) peer use. Current policy is to process officers and senior sanction of drinking on the job, (5) official sanction enlisted personnel for discharge after the first de- of heavy drinking, (6) separation from normal sexual tected drug offense but to give junior enlisted per- or social relationships, (7) opportunity to obtain sonnel a second chance to prove themselves. This alcoholic beverages relatively inexpensively, and policy is at odds with a concurrent DoD policy of (8) preponderance of young workers in the occupa- encouraging individuals with alcohol problems to tion. Whitehead and Simpkins found that 70% of seek help, and the two are frequently confused. the variance in the rate of alcohol problems could be Thus, 58 percent of respondents to the 1988 World-

65 Military Psychiatry: Preparing in Peace for War wide Survey expected disciplinary action would be Abuse and Alcoholism Prevention, Treatment, and taken against a person seeking treatment for an alco- Rehabilitation Act of 1970,15 better known as the hol problem, and 60.9 percent expected it for a drug Hughes Act. Signed by President Nixon, against the problem.26 The best evidence to represent the barrier urging of influential Cabinet members,34 the Hughes of fear is that one-third of respondents believed that Act provided the country’s first comprehensive those who sought help for an alcohol problem would national policy on alcoholism since the repeal of damage their careers although military policies en- Prohibition. Among its provisions, it mandated alco- courage rehabilitation. Although the healthcare pro- holism treatment and rehabilitation for federal em- vider may not be capable of changing this mass psy- ployees, prohibited hospitals that received federal chology, it is important to recognize its presence and funds from discriminating against the admission and its power to drive avoidance treatment-seeking and treatment of alcohol abusers and alcoholics, safe- treatment-offering behavior. guarded the confidentiality of records of alcoholic The medical and psychiatric literature, how- patients, and established the National Institute on ever, has consistently expanded the biological Alcohol Abuse and Alcoholism as a catalyst for foster- understanding of . Many neu- ing programs to identify and rehabilitate alcoholics rophysiologic research efforts have supported with special emphasis on the workplace. Public Law the notion that drug-craving behavior and re- 92–129 made it clear that the military also had to carry petitive drug and alcohol use may be linked to out the policies stated in the Hughes Act. It thus gave alterations in the neurochemical milieu.27,28,29 impetus to the significant expansion of alcoholism Genetic factors are also postulated, especially in treatment programs in the military services. alcoholism,30,31 particularly among Native Ameri- In the meantime, the narcotic problems emanat- cans and Asians who have low levels of alcohol ing from Vietnam ended with the withdrawal from dehydrogenase. In addition, life-cycle studies Vietnam. There was also an upsurge of narcotic show an increased incidence of alcohol and sub- abuse in troops stationed in Europe during the stance abuse in adults who have a history of 1970s, particularly with intravenous heroin. This attention deficit disorder as children.32,33 drug abuse also created a epidemic, re- quiring massive air evacuation of these soldiers to Public Law the continental United States. As the substance abuse policy was implemented 1971 marked a turning point for military sub- and expanded, military and civilian personnel were stance abuse treatment because of the enactment of trained specifically for the ADAPCP, and treatment specific legislation that directed the Secretary of facilities were created, expanded, and evaluated. In Defense “to identify, treat and rehabilitate mem- addition, urine testing was implemented for the bers of the Armed Forces who are drug or alcohol massive screening of drugs within the military. This dependent.”3(p646) This legislation, Public Law 92– impetus has since resulted in the successful pro- 129, required the military to participate in full com- gram of prevention, control, and treatment of sub- pliance with the earlier Comprehensive Alcohol stance abuse as it currently exists.

DIAGNOSIS AND DEFINITIONS

Diagnosis The U.S. Army (and all of DoD) uses the Interna- tional Classification of Diseases (ICD) system. The During the early 1900s, the U.S. Army classified ICD-Clinical Modification (ICD–CM) and the Diag- drug and alcohol addiction separately from mental nostic and Statistical Manual of Mental Disorders (3rd diseases. In other words, drug and alcohol prob- ed., revised, DSM III–R),35 which is correlated with lems without a physical or mental disease were the ICD-CM, are used in the United States for diag- considered as nonmedical disorders. Current policy nostic purposes. still dictates medical and nonmedical disposition of soldiers identified with a psychoactive substance Definitions use, abuse, or dependency problem, despite the considerable evidence28 that suggests that these dis- The following terminology is frequently encoun- orders are genetically and physiologically based. tered in substance use disorders.

66 Alcohol and Drug Abuse and Dependence

• Substance refers to alcohol, drugs, or any Dependence Syndrome chemical that, when taken, affects the physi- cal and mental functions of an individual. The dependence syndrome associated with psychoactive substances is the hallmark of these ad- • Substance use refers to the consumption of dictive disorders. It is multidimensional with biologi- alcohol or other psychoactive drugs that can cal, social, and behavioral components. The loss of have negative effects on the person’s social, control over the substance use is the cardinal feature of occupational, or physical well-being. this syndrome. The syndrome elements are as follows: • Substance abuse is a pattern of use that re- sults in negative consequences although • Substance use takes on a regular schedule these effects may not be visible or even of almost continuous or daily use. recognized by those in the environment.3 • Substance use becomes a higher priority than any other activities despite negative • is a condition, psycho- consequences. logical or physical, of interaction between a •Increased tolerance develops. person and substance, characterized by a •Withdrawal symptoms occur. compulsion to take the substance on either • The substance is used to avoid withdrawal. a continuous or a periodic basis to experi- •A compulsion to use the substance develops. ence its psychological effects or to avoid • Readdiction liability is possible. the discomfort of its absence. • Physical dependence is an altered physi- Most of the above syndrome elements have been ological state brought on by the frequent incorporated in the current DSM III–R criteria for use of a substance and resulting in physi- psychoactive substance dependence. Because the ological symptoms on withdrawal. Note military services apply the DSM III–R criteria for that one may become dependent on a diagnostic purposes, it is essential that familiarity substance without abusing it or being with the criteria is established. See Exhibit 5–1. addicted to it as in cancer or Although tolerance and withdrawal are symptoms patients. that are listed in the DSM III–R criteria for depen- dence, these two symptoms are not required to • is substance depen- make the diagnosis of dependence as had been in dence without the physiological evidence the original DSM III37 system. To diagnose depen- of dependence. dence, it is necessary to fulfill only three of the nine • Tolerance is the altered physiological state DSM III–R criteria. In addition, social and occupa- produced by the continuous use of a sub- tional impairment has also been deemphasized as stance with the declining effect of the given being essential in the current DSM III–R diagnosis dose.3,36 of either dependence or abuse.38

DETERMINANTS OF SUBSTANCE ABUSE

Individual Determinants Although polydrug abuse has not been conclu- sively linked to genetic factors, studies in alcohol- The use and abuse of psychoactive substances, ism have shown evidence of genetic linkage.32 These along with the dependence syndrome, are studies indicate that a child of an alcoholic has a multidetermined. The military population being a greater risk of developing alcoholism than a child of subsample of the general population is made up of nonalcoholic parents, even when adopted by individuals of various ages, personalities, and back- nonalcoholics at birth.31,39 There has also been noted grounds. They thus share the biological, psycho- physiological differences between children of alco- logical, and social vulnerabilities of the general holics and those of nonalcoholics in their biological population. The individual determinants are sig- response to alcohol and other in their nificant because the constitutional vulnerabilities central nervous system function.28 are present within the soldier and, given a set of Personality appears to play a more important circumstances, an emergence of the substance abuse role in the genesis of polydrug abuse than in alco- disorder can occur. holism. Drug abusers frequently display severe

67 Military Psychiatry: Preparing in Peace for War

EXHIBIT 5–1 DSM III–R DIAGNOSTIC CRITERIA FOR PSYCHOACTIVE SUBSTANCE DEPENDENCE AND ABUSE

I. Dependence 50% increase) to achieve intoxication or desired effect, or markedly diminished ef- A. At least three of the following: fect with continued use of the same amount 1. Substance often taken in larger amounts 8. Characteristic withdrawal symptoms or over a longer period than the person intended 9. Substance often taken to relieve or avoid 2. Persistent desire or one or more unsuc- withdrawal symptoms cessful efforts to cut down or control B. Some symptoms of the disturbance have per- substance use sisted for at least 1 month or have occurred 3. A great deal of time spent in activities repeatedly over a longer period of time. necessary to get the substance, take the II. Abuse substance, or recover from its effects A. A maladaptive pattern of psychoactive sub- 4. Frequent intoxication or withdrawal stance use indicated by at least one of the symptoms when expected to fulfill major following: role obligations at work, school, or home, or when substance use is physically haz- 1. Continued use despite knowledge of per- ardous sistent or recurrent social, occupational, psychological, or physical problems that 5. Important social, occupational, or recre- are caused or exacerbated by use of the ational activities given up or reduced psychoactive substance because of substance use 2. Recurrent use in situations when use is 6. Continued substance use despite knowl- physically hazardous edge of having a persistent or recurrent social, psychological, or physical prob- B. Some symptoms of the disturbance have per- lem that is caused or exacerbated by the sisted for at least 1 month or have occurred use of the substance repeatedly over a longer period of time. 7. Marked tolerance: need for markedly in- C. Never met the criteria for psychoactive sub- creased amounts of the substance (at least stance dependence for this substance.

personality disorders of the antisocial or borderline are experienced by all but to which each soldier’s type. Psychological and personality characteristics reaction differs depending on individual strengths. of drug-abusing persons most often have been re- Young soldiers tend to face insurmountable ob- ported as impulsive and novelty seeking.39 stacles to a sense of personal identity and unit Social maladjustment and environmental depri- affiliation by the high level of turbulence in the vation likewise are significant as determinants of units, the geographical separation from friends and substance abuse. This finding is more true with family, and the psychological isolation from offic- polydrug abusers.40 ers, noncommissioned officers, and the surround- ing community. Environmental Determinants Excessive drinking has been associated with mili- tary personnel, and active duty has been considered Substance abuse like any other behavior is the to be a high-risk occupation for alcoholism. That the product of an individual interacting with his envi- military environment contributes to alcohol use ronment. In any organizational management of sub- and abuse has been frequently cited.1,2,3,17,19 Studies stance abuse, it is therefore essential to understand have also indicated little change in patterns of alco- the environment in which the disorder occurs. The hol use over the years.3 In a survey among military military environment has its unique stressors, which personnel, there was a definite relation between

68 Alcohol and Drug Abuse and Dependence stress at work and alcohol consumption.26 demonstrated during the Vietnam conflict when It has been noted that the pattern of substance the use of narcotics dramatically increased due to use among soldiers is determined less by pharma- its availability and low cost. In addition, many who cological and personality variables and more by the were regular drinkers, including some who had circumstances, such as substance availability, peer drinking problems, switched to opiates and then pressure, and need for affiliation in an environment became opiate dependent. After the Vietnam con- in which social supports tend to be lacking and in flict, opiate use decreased, and alcohol use again which loneliness and isolation abound.41,42 Drugs became ascendant.46 A study of soldiers returning have been used as a way of “bolstering self-esteem from the Republic of Vietnam (RVN) in 1971 dis- through identification with a group, to reduce anxi- closed “less than l% ever addicted to narcotics be- ety, and to provide themselves with an interper- fore arrival in RVN; while in RVN, 1/2 of them used sonal relationship.”43(p448) narcotics and 1/5 reported opiate addiction. After Combat, the most significant stressful situation their return to the US, usage and addiction de- in the military, generally tends to increase sub- creased to pre-Vietnam levels.”47 Similarly, the 1990 stance use. A study of veterans of the Korean and to 1991 Persian Gulf War saw an absence of alcohol Vietnam conflicts indicated “a significant associa- problems because of strictures against importation tion between combat exposure and excessive alco- of alcohol into Islamic countries. hol use.”44(p572) Many veterans of the Vietnam con- flict began using heroin during their tour of duty for Organizational Determinants relief of fear and tensions of war. Abuse of heroin, , and alcohol by combat soldiers was not The level of stress present within the unit im- usual while in the field in close proximity with the pacts on its members significantly. As a result of enemy but rather was usual while back at the fire leadership difficulties or organizational problems, base or on rest and recreation. Apparently, the the soldiers in the unit can experience a significant desire for survival mobilized peer pressure to keep amount of discontent, frustration, and poor morale. soldiers alert while on patrol. For other soldiers, Problems in behavior among the troops rise signifi- boredom and the lack of meaningful activity con- cantly, and substance abuse rates tend to rise ac- tributed to substance use.45 cordingly. Therefore, in any situation in which sig- nificant substance abuse is determined, a command Availability consultation with the unit is indicated, and organi- zational functioning needs to be assessed. Primary There can be no widespread substance abuse preventive measures could significantly reduce the without its availability. This situation was clearly abuse rates in dysfunctional units.

CURRENT THEORIES

Biopsychosocial or social (peer influences) predispositional fac- tors. Stressful life events or psychological condi- Soldiers may take substances for many reasons. tions (anxiety, , depression, and so forth) These reasons include curiosity, peer pressure, and precipitate increased drinking, and the drinking the desire to diminish dysphoric feelings or experi- becomes progressive as alcohol in these suscep- ence euphoriant feelings. Drug use among young tible individuals provides relief by producing soldiers is generally experimental and tends to be euphoria or alleviating the . As a con- confined to social situations that often provide a sequence, primary psychological dependence is focus for group interactions and identity.1 This type developed resulting in tolerance. Physical de- of substance use is quite different from regular use pendence follows with the need to drink to pre- or dependence. vent withdrawal symptoms. The established ad- Today, the biopsychosocial theory is the domi- dictive cycle is then intensified by the protracted nant concept in alcoholism. The theory postu- syndrome with persistent psychologi- lates that certain susceptible individuals are more cal craving. Even after a period of abstinence, likely to develop because of and this period can last many years, because the biological (genetic), psychological, (depression), physical dependence mechanism remains, the ad-

69 Military Psychiatry: Preparing in Peace for War dictive behavior becomes reactivated by alcohol more often familial than with Type 2, often with ingestion.39 both their parents having a similar pattern. There is little or no criminality. Because of the loss of control Subtypes of Alcoholism and prominent psychological dependence, the treat- ment goal should be a total, lifelong abstinence. Military experience has indicated that alcohol- Supportive social relationships and appropriate ism is manifested in different ways among soldiers. means of relieving anxiety are also essential for What is frequently seen among the younger sol- recovery.28 diers is not the same as what is seen with older Those with Type 2 alcoholism are typical alcohol soldiers. Studies31,39 of families with alcoholism and abusers, characterized by the onset of moderate adoption studies28,39 have clarified these impres- alcohol abuse during their teenage years (before the sions by the determination of two clinical subgroups age of 25). They drink to seek stimulation and plea- of persons with alcoholism that differ in their ge- sure and present a history of frequent criminality netic and environmental backgrounds.28 These sub- with arrests, suicidal acts, and other acting-out be- types imply different approaches for the manage- havior. Generally, there is a history of an early onset ment and the treatment of alcoholism in the military. of alcohol abuse and criminality in their biological Type 1 alcoholism is the classical alcohol-depen- fathers. Antisocial personality characteristics are dent person with a loss of control and the compul- common with impulsive and aggressive behavior. sion to drink. Type 1 alcoholics are generally anx- They tend to be risk takers who abuse a variety of ious or passive-dependent and drink to relieve the substances in addition to alcohol. The alcoholism is anxiety. They may experience prolonged and se- manifested by an inability to abstain, fighting while vere depressive responses to separation or loss of drinking, and drinking and driving recklessly. social attachments. For this group, mild or severe Women seem less at risk for the Type 2 alcoholic alcohol abuse occurs after the age of 25 years, and disorder than do men. Treatment should be heavily tolerance and dependence develop rapidly on drink- directed toward seeking other ways to obtain stimu- ing. They tend to display recurrent binges, guilt lation and pleasure, that is, physical activities in about drinking, and liver disorders. The disorder is addition to developing self-control.28

IDENTIFICATION

Substance abusers are quite unlike the usual pa- drug use. For alcohol, are a rapid tients that a physician sees in two major respects. means of ascertaining the level of blood alcohol First, the typical medical patient is motivated by his present for treatment purposes; however, when- distress and discomforts to seek relief. The drug ever a need arises for a legal determination of abuser does not consider himself ill or his activity blood alcohol concentration (BAC), a laboratory undesirable. It is only when he suffers from intoxi- analysis of the blood sample is necessary, utiliz- cation, withdrawal, or other effects of substance use ing proper procedures and a chain of custody. that he is brought to medical attention, and then Usually, commanders have the authority to or- usually as a referral by his commander. Second, der such testing. although the treatment of the physical effects of substance use is a medical responsibility, the treat- Urinalysis ment of the (rehabilitation) is a command responsibility. Urinalysis testing is useful for detecting sub- Unlike with most other medical disorders, the per- stance use such as cannabis, cocaine, amphetamines, vasive existence of denial among substance abusers phencyclidine, barbiturates, and opiates. Testing is maintains the drug use and perpetuates the disorder. done under strict procedures to minimize adminis- The motivation for recovery is often provided by the trative errors because a soldier’s career may be threat of career termination because the military ser- determined by its result. Commanders often utilize vices have considered continued substance abuse to random urine testing for drugs. For both alcohol be incompatible with military service. and drugs, commanders have the prerogative of Biochemical testing is used widely within the ordering testing whenever there is a suspicion of military services for the detection of alcohol and use or impairment.

70 Alcohol and Drug Abuse and Dependence

The physician plays a key role in the evaluation absenteeism, tardiness, personality changes, disin- of all confirmed laboratory tests because prescribed terest, argumentativeness, accidents, and sickness. drugs can give an erroneous impression of abuse. This is true largely in the lower enlisted ranks. The physician assesses all available data, including Among the higher enlisted ranks and officers, medical records, examines the subject, and renders impairment is quite subtle and less conspicuous. a diagnosis and recommendations. It is important Therefore, identification is more difficult. Here, that physicians work closely with the commander a recognition of longer lunch breaks with a smell in obtaining all pertinent information before any of alcohol on the breath may be a clue to an final decision is made that the individual is or is not alcohol problem. Identification based on perfor- a substance abuser. To assist the physician, ques- mance becomes an especially difficult task. The tionnaires such as the Michigan Alcoholism Screen- performance requirements of jobs differ, and the ing Test (MAST)48 and the CAGE49 (Have you tried higher status jobs allow more variation in work to Cut down? Are people Angry when you drink? performance. Furthermore, the senior service Do you feel Guilty about drinking? Do you take an member has less immediate supervision, more Eye-opener in the morning?) are available and eas- privacy, and more opportunity to set his own ily administered and scored. pace and hours, and there are fewer opportuni- A proper diagnosis of substance abuse disorder is ties for accidents. In addition, there is less social essential in ensuring proper intervention, treatment, distance and more collegiality between the higher and follow-up. The physician should be objective in enlisted ranks and officers and their supervisors. considering the needs of both the individual and the These supervisors are often reluctant to acknowl- organization rather than “protecting” the person, as edge that a problem exists. sometimes occurs. In addition, the primary concern of Within the DoD, any person having a blood all professionals should be to encourage substance alcohol level of 0.05 percent while on duty is abusers voluntarily to seek assistance and to eliminate considered impaired and should not continue to those factors that prevent this assistance. work. “Alcohol is a primary and continuous de- pressant of the central nervous system. In per- Medical Screening sons intolerant of alcohol, impairment of judge- ment and of recently learned, complex, and finely An important means of detection is available to tuned skills begins to occur at BACs as low as 5.4 the physician attending to “sick call.” Conditions mmol per liter (0.025 percent), followed by the such as hepatitis, recurrent Monday “flu” syn- loss of more primitive skills and functions, such dromes, and may indicate substance abuse. as gross motor control and orientation, at con- Alcohol misuse can aggravate almost any of the centrations in excess of 11 mmol per liter (0.05 routine complaints and findings seen in the every- percent).”50(p456) day practice of medicine, particularly neurological, For troops in combat or in the field, the prob- gastrointestinal, and cardiorespiratory symptoms. lem is especially critical as impairment in infor- Physicians should always consider substance abuse mation processing occurs even at minimal blood in any recurrent or nonspecific medical conditions levels. The ability to abstract and conceptualize and recurrent injuries. is diminished along with the cognitive ability to interpret incoming information. The soldier is Commander’s Suspicion also less able to appreciate the potential danger or the negative consequences of a particular ac- For commanders, the usual means of identifying tion because alcohol tends to cause him to act alcoholism is based on performance criteria such as impulsively.50

TREATMENT

For many years, alcoholism as a treatable condi- understood of its mechanisms and phenomena in tion was ignored by the military as well as by the order to develop more effective treatment. medical community. Little was known then of alco- In the past, while the military had a variety of holism as a disease. While great strides have been mechanisms for handling alcoholic dereliction of made in its understanding, much more needs to be duty, it lacked treatment programs. As a result, the

71 Military Psychiatry: Preparing in Peace for War soldier’s denial was echoed by the military because setting is that the use of a substance has the poten- commanders seldom wished to terminate what had tial of modifying the relationships existing in small been a promising career. Soldiers with confirmed groups.55 Drug use can be disruptive to unit cohe- alcoholism were put in the same category as those sion because it can fragment the unit into disparate with mental deficiency or psychopathic state, and groups. The unit cohesion that is so vital in sustain- they were considered to be constitutionally handi- ing the soldier in battle can be compromised.56 capped. “Their separation from the army under the Since the inception of treatment as an alternative appropriate administrative regulation was in the in the management of substance abusers, programs best interest of the soldier and the service.”51(p590) have been made available in each military installa- Alcoholism was considered a result of willful tion. The thrust has been along voluntary treatment misconduct, and the punitive approach was the and early intervention. Both outpatient and inpa- usual means of management. However, medical tient modalities are available and current programs personnel felt that treatment should be offered to match the intensity of treatment to the needs of the the afflicted soldier rather than punishment. patient at hand. The current treatment policy is more favorable in the military for those with alco- Alcoholism was a difficult problem. There was of- holism. There is less tolerance for other substance ten doubt whether a “drunk” belonged in the local abusers.3 guardhouse or in the hospital, where possible in- tracranial injuries for example, could be detected. A compromise solution was reached when one of the Triage neuropsychiatric closed wards was assigned to care for such problem personnel. Acute alcoholics were The ADAPCP in the U.S. Army is a command admitted to this ward and then transferred to the program.57–59 By this policy, the commander makes guardhouse if no medical disorder existed. This was the decision of whether the soldier should receive in accord with Army policy that regarded alcohol- ism as misbehavior rather than illness.”52(p814) rehabilitation for his substance abuse disorder. Unlike other treatment, the medical officer can rec- For those fortunate enough to be placed on the ommend, but the commander makes the final deci- psychiatric service, alcoholism was invariably con- sion. Generally, the commander bases his decision sidered to be a symptom of some underlying psy- on the soldier’s performance and his potential for chiatric disorder. Even so, long-term treatment of further active duty, that is, the soldier’s past and such a condition was unavailable in the services. future contributions to the military. Although there was some early work done in the The treatment of the effects of drugs and alcohol hospital treatment of alcoholics at various military as they are manifested physically is a medical re- treatment centers,3 it was only after 1970 that a clear sponsibility. However, once the condition stabi- policy had emerged in abandoning the willful mis- lizes and the soldier is no longer in danger, the conduct concept and that took a more humanitarian commander decides on whether the soldier receives and therapeutic approach. The U.S. Army initiated rehabilitation or administrative action, including its ADAPCP in 1971 on a congressional mandate.53 separation. The program approach was in large part a result of As indicated previously, substance abusers can the policy of conservation of manpower because generally be divided into the two types. Within the senior noncommissioned officers and officers rep- military, this division can be done quite easily. resented a considerable financial and experiential Considering the differences in characteristics and investment by the military. The military services symptomatology, the treatment implications are could not afford the constant replacement of highly enormous. Soldiers of the Type 1 group will be skilled service members and the ongoing toll of considered more likely to have the disease of alco- impaired performance and hazards associated with holism and thus benefit from the medical approach, substance use.17 It had been clearly shown previ- that is treatment in the residential treatment facility ously26 that substance use correlated highly with (RTF). Soldiers of the Type 2 group would receive the occurrence of physical symptoms, social dis- only limited benefits from the purely medical ap- ruption, and the deterioration of work performance. proach. Their management should include a signifi- Providing treatment favorably affected health and cant command approach, utilizing discipline, struc- performance.54 ture, training, and administrative action. An effect that may not be as important in other Although there are exceptions, with a large pro- settings but is highly significant within the military portion of the military population being less than 25

72 Alcohol and Drug Abuse and Dependence years old, it appears that a great majority would fall bilitation are expeditiously separated. These indi- into the Type 2 group with the diagnosis of alcohol viduals are, however, given the opportunity for abuse. Occasionally, soldiers referred for alcohol treatment at a Veterans Administration medical intoxication or an alcohol-related incident may not facility within 30 days of separation. fit into the DSM III–R criteria for alcohol abuse. This also occurs with some soldiers who test positive on Outpatient urinalysis for substances. In these cases, because no definitive diagnosis can be made, the soldier is The outpatient treatment modality is the first considered to have used the substance improperly. treatment intervention. The usual entrance reason He is therefore enrolled into the education pro- is an alcohol-related incident. A psychoactive sub- gram, usually for a 30-day period. The staff may stance use disorder60 diagnosed by medical person- use this time to further observe and evaluate the nel following a comprehensive clinical assessment soldier. is necessary for enrollment. The outpatient pro- gram usually consists of weekly group counseling Treatment Strategies sessions and individual sessions as necessary. Treat- ment plans also include AA participation and Although soldiers entering into a treatment pro- as indicated. (NA) gram, whether outpatient or RTF, have different and Cocaine Anonymous (CA) may be utilized when degrees of the disorder with differences in need, substances other than alcohol are abused. Periodic they all require restoration and changes in their urinalysis is also utilized to discourage the substi- basic behavior to pursue recovery. Within the sub- tution of other psychoactive substances. The com- stance abuse field, there is yet no cure. For many, mander enrolls the soldier into the program on the abstinence is the goal, and recovery is a lifelong recommendation of the professional staff. For the task. The strength of one’s recovery program mini- duration of the soldier’s treatment, there is active mizes the slips and . Treatment strategies collaboration with command. The commander pro- emphasize various means to avoid drinking, in- vides the direction, structure, and limits that are cluding taking disulfiram and attending Alcoholics necessary in rehabilitation. The program is espe- Anonymous (AA) meetings. Strategies are also di- cially suited for the young soldier who abuses rected to repairing social and medical problems, alcohol. restoring hope and self-esteem, and developing new interests and associations.36 The establishment of a Residential Treatment Facility new social network along with substitute behavior is also critical. Inpatient treatment of alcoholism and other drug For treatment to be effective, a comprehensive dependence is conducted in one of the many mili- approach is necessary. Every area of the patient’s tary RTFs. For those soldiers that are alcohol- or functioning should be assessed and addressed be- drug-dependent by DSM III–R criteria, it supple- cause these individuals display multiple impair- ments and augments outpatient care. It is a hospi- ments by the time they come to treatment. These are tal-based program of intensive therapy, lasting 4 to behavioral difficulties, psychological disturbances 6 weeks and followed by outpatient treatment for (mood and affect), social-interpersonal impairments, the next year. Community living milieu and inten- and physical and cognitive dysfunctions. In addi- sive group therapy to overcome denial and to tion, the adverse effect on work performance and effect lifestyle changes are heavily utilized. Coun- legal difficulties, if any, need resolution. seling and education with intensive AA/NA par- When an abuser enters treatment, the outcome is ticipation are included. If not medically largely dependent on the service member’s motiva- contraindicated, disulfiram (Antabuse) is encour- tion to remain in the service by giving up the use of aged as an adjunct to treatment. Because of the substances of abuse. A service member must not effect of family dynamics in the treatment pro- only comply with the treatment plan in terms of cess, family issues are addressed and many pro- attendance and participation, but he must demon- grams include spouses and other codependents strate an actual change in attitude, abstention from to support the rehabilitation of the individual substance abuse, and a satisfactory duty perfor- and to prevent further enabling.3 It is an inten- mance. With readiness for duty as the policy in the sive but time-limited recovery program with ab- military, service members not motivated for reha- stinence as its goal.

73 Military Psychiatry: Preparing in Peace for War

To continue the recovery process initiated in the geographically in his unit and reenlistment con- RTF, at the time of release, a sound aftercare plan is tracts cannot be negotiated. This is to maintain the prepared. The service member is referred back to continuity of treatment at one location as well as to his own military community’s outpatient facility allow the commander the continued assessment of for continued care according to its outpatient for- the soldier. Adequate medical follow-up is also mat (ie, weekly counseling sessions, disulfiram necessary during this period because of the recur- therapy, and AA attendance) for the next year. rent medical problems that many alcoholics have Commanders are involved in the aftercare, and developed over the years. In addition, because of their support is considered essential for the service the tendency to substitute other drugs for a previ- member’s return to duty, compliance with treat- ous alcohol dependency, the physician should be ment, and ultimately assurance of adequate reha- acutely sensitive to the use of medications by the bilitation. The year of aftercare is a probationary soldier for any reason. It may be necessary periodi- period during which a service member is stabilized cally to subject the soldier to random urinalysis.

MANAGEMENT OF CLINICAL CONDITIONS

Of importance in the treatment and management ness should not be confused with alcoholism. It is seen of substance-induced disorders is an understand- in both alcohol abuse and alcohol dependence. Intoxi- ing of the disorder and its psychosocial aspects. cation is often defined, especially in relation to driving Proper treatment utilizes the various psychiatric offenses as a BAC of 100 mg per 100 ml of blood. treatment modalities, including both pharmacologic and psychosocial approaches. The goal is to restore A —defined as 44 ml (1.5 oz) of the soldier’s functioning in the military milieu and distilled liquor (80 proof, or 40 percent alcohol by correct any performance deficits. Appropriate man- volume), 360 ml (12 oz) of beer (5 percent alcohol) or agement utilizes the support of the community, 150 ml (5 oz) of wine (12 percent alcohol)—contains about 15 g of alcohol, and in a 70-kg person the family, unit, and organization to optimize recovery. ingestion of one such drink will result in a peak Essential in the management is the understanding blood alcohol concentration of approximately 4.3 to of the soldier’s personality and circumstances that 8.7 mmol per liter (0.02 to 0.04 percent), depending 61 led to the disability or illness. on the rates of ingestion and absorption. Alcohol is Two frequently encountered complications seen metabolized and eliminated from the body at an among soldiers are alcohol- or drug-induced in- average rate of about 8 g per hour; thus, for each toxication and psychoses. Intoxications are acute standard drink consumed, approximately two hours disorders that require immediate treatment. The are required for the blood alcohol concentration to psychoses may be acute or chronic. The with- fall to near zero, though slow rates of absorption may prolong the tail of the elimination curve be- drawal delirium is one type that requires imme- yond two hours.”50(p456) diate intervention. The standard treatment for psychosis differs in Sporadic, deliberate intoxication and voluntary the treatment of the substance-induced psychotic heavy drinking (drunkenness) must be distin- disorders; however, both may include the use of guished from the disease of alcoholism or alcohol neuroleptics and appropriate supportive measures. dependence. Drunkenness is usually a hallmark of Elimination of the toxic substance and correction of an alcohol abuser, but a history of repeated epi- metabolic diatheses is of paramount emphasis in sodes points to dependence. substance-induced psychoses. The treatment of al- varies in degrees and may cohol intoxication and alcohol delirium will follow. be associated with abuse of other substances. Usu- The measures utilized in these disorders can be ally, the pure alcohol intoxication tends to be un- utilized in similar conditions that are drug-induced. complicated, and recovery is fairly rapid. Because Alcohol Intoxication of the social and other supports that are not avail- able in barracks living, soldiers are often hospital- Among the troop population, intoxication plays ized briefly to avoid any unforeseen complications a major role in the morbidity and mortality associ- and to ensure safe recovery. ated with accidents, homicide, , and medical The usual signs of intoxication are slurred speech, and surgical conditions. Intoxication or drunken- nystagmus, hyporeflexia, unsteady gait, incoordi-

74 Alcohol and Drug Abuse and Dependence nation, flushing, somnolence, and drowsiness. A insistence of his parents and because he had no job. strong alcoholic breath is usually apparent but may Since arrival at his unit, he has had two incidents of be absent if unperfumed vodka has been ingested. fighting while intoxicated and was charged twice for dis- Effectively treated with bed rest, recovery is fairly obeying orders. He had also tested positive for cannabis rapid. To control excitement or violence, careful a month ago. On release from the hospital, he was restraint may be needed. The use of medications is enrolled in the outpatient program by his commander. Attendance at the group sessions was erratic, and when controversial because deaths have occurred with he attended, he minimally participated. When confronted, additional sedation and important neurological he became hostile and defensive. He refused disulfiram, signs may be masked. allegedly because he had no intention of quitting alcohol. Severe intoxications (alcohol overdose) present A repeat of his urine drug screen a few weeks later again potential respiratory, cardiovascular, and central was positive for cannabis. Because of his failure to benefit nervous system complications, including coma. from treatment and the continued use of an illegal sub- There is also the possibility of unpredictable behav- stance, he was disenrolled from the program by his ioral manifestations. Because the primary approach commander and separated administratively from the to the management of these individuals is life sup- service. Comment: Soldiers who have had alcohol and drug port, these cases should be managed in the hospital problems before entering on active duty often experience intensive care unit. a during their term of service. Motivation for Severe intoxication is seen most often among treatment is perhaps the best predictor of success. The young soldiers in a foreign country who, unfamiliar individual in the above case study had no motivation to with the alcohol content of the local beverages, stop drinking. consume a significant quantity in a short period of time. It can also occur in binge drinkers who drink Case Study 2 enormous quantities of alcohol rapidly. Because drugs may also be involved, it is necessary to obtain not only a BAC but also a drug screen. Because A 21-year-old serviceman with 2 years of active duty was brought to the base dispensary after he passed out at identification of the specific substances may not be the local bar. He had been in Korea a week when he immediately available, familiarity with substances decided to try the clubs with his fellow soldiers. At their available in the local community is helpful. An insistence, he had two bottles of Soju, a Korean drink, and example in South Korea is Soju, a beer with a high- four bottles of beer over a period of 2 hours. When seen alcohol content. at the hospital, he was drowsy but responsive. BAC was Optimal management and treatment presuppose 0.25 mg% for alcohol. He was admitted into the hospital that the clinician has a clear appreciation of the for observation. The recovery was uneventful, and he clinical situation, including an adequate history required no medications. Continued observation indi- and physical examination. Appropriate laboratory cated no emergence of tremors or withdrawal symptoms. Additional history indicated that the patient had been support is also essential. However, when a soldier drinking for the past 4 years and that at his last duty post is brought in by the military police or by ambulance, he had been cited for driving while intoxicated. He usually reliable and accurate information may be lacking. It drank on weekends with fellow soldiers and had been is often necessary to start treatment immediately on drunk on several occasions at parties. Following his a high index of suspicion as to the psychoactive release from the hospital, he was enrolled in the outpa- substances involved. tient program by his commander because he was gener- ally considered a good soldier. He received weekly group counseling, attended the local AA meetings, and com- Case Study 1 plied with the program requirements for the 6 months of his enrollment. During treatment, there was active com- A 20-year-old serviceman with 8 months of active duty mand collaboration and consultation. The soldier was well was brought to his medical treatment facility by the mili- aware of potential administrative action, including sepa- tary police for treatment of a head laceration following his ration, should he fail to progress in the program. He apprehension for fighting at the club. When seen, he was successfully completed the program and remained intoxicated with a BAC of 0.15 mg% of alcohol and was free of any alcohol-related incidents for the next year hostile and belligerent. For the treatment of his wound and when he was honorably discharged on his expected for observation, he was admitted into the base hospital. termination of service. He recovered from the incident uneventfully over the next Comment: The above case study illustrates a success- day. Past history indicated that he had been drinking for ful outcome of a soldier placed in the outpatient treatment the past 5 years and was apprehended a year ago for program. It is estimated that 60% of those enrolled in the driving while intoxicated. He entered the army at the outpatient program are successfully rehabilitated.62

75 Military Psychiatry: Preparing in Peace for War

Case Study 3 Detoxification is the first step in the treatment of addiction; the ultimate goal is recovery through a A 42-year-old Sergeant First Class returned from de- continuing treatment program. It should be per- ployment to Panama to find his wife had begun having an formed in an adequate treatment setting, preferably affair with a neighbor and wanted a divorce. The soldier, a hospital setting, because convulsions and delirium originally from City, returned home on leave to can occur. Symptoms of withdrawal can begin as be with his family of origin for support and solace. On a early as 8 hours or as late as 72 hours after the last dare, he used crack cocaine and noted that this drug drink. Information useful in the treatment of the helped with his feelings of dysphoria surrounding the breakup of his marriage. When he returned to his duty alcohol withdrawal syndrome is the drinking his- station, the soldier moved to an apartment in town and tory (duration, amount and pattern to ascertain the began using crack cocaine on a regular basis. His work degree of tolerance, and blackouts), the history of performance declined and he tested positive on a random signs and symptoms of physical dependence, (early urine drug screening. morning shakiness, nausea, and nightmares relieved During his referral to the ADAPCP, a psychiatric evalua- by drinking), and the manifestations of previous tion confirmed the presence of an with withdrawal, particularly DTs and .61 depression. He readily engaged in outpatient counseling The withdrawal syndrome ranges from mild to and his command began processing his separation. severe. The mild withdrawal syndrome is usually The soldier received 8 months of drug abuse counsel- ing before being separated from the service. One year self-limited, resembling a hyperadrenergic state. It after separation, he was still doing well and had found is manifested by anxiety, tremors of hands, dia- another job in the defense industry. phoresis, tachycardia, systolic hypertension, mild Comment: Despite the regulation that mandates separa- nausea, and sleep disturbance. It typically appears tion because of drug use, soldiers can still receive benefits within 12 to 24 hours after the cessation of drinking, from evaluation and treatment while awaiting separation. and the duration is usually 3 to 4 days.61 Many of these patients require only observation, reassur- Alcohol Withdrawal ance, and comfort with little or no medication. When in the field, these cases can best be managed in a The objectives in treating alcohol withdrawal are setting that can render supportive care, such as the relief of discomfort, prevention or treatment of hydration, nutrition, rest and sleep, reassurance, complications, and preparation for rehabilitation. and orientation. However, for those that have a Withdrawal symptoms usually occur in persons long history of drinking and evidence of depen- that have developed tolerance and are alcohol-de- dence, this may be risky because they can easily pendent in contrast to abusers of alcohol. With- progress in symptomatology and there is more risk drawal syndromes are usually seen in situations of of complications. voluntary abstinence, in treatment centers where The severe form of withdrawal, with DTs is character- the soldier is being treated for an intercurrent dis- ized by a symptom complex of profound confusion, ease or trauma, in custody of military police, or disorientation, , agitation, and autonomic during troop movements. Although cessation of hyperactivity. It appears 3 to 4 days after the cessation of drinking is the usual cause of the emergence of the drinking and resolves in the next 5 days with adequate withdrawal syndrome, it can be precipitated by re- treatment. The dangers are hyperpyrexia, dehydration, duced consumption or by any intercurrent illness, and electrolyte imbalance.36 particularly infectious diseases. Because of inability to The withdrawal syndrome requires prompt treat- control their drinking, these individuals may display ment and continual close attention to avert compli- impairments in performance, and social relations, cations. The possibility of simultaneous withdrawal legal difficulties, and medical complications. from other drugs should always be considered. For In the case of drugs (alcohol, barbitu- this reason, serum or urine drug screen as well as rates, sedatives, or ) untreated withdrawal corroborative information is essential for proper can be lethal. With narcotics, the withdrawal, al- management. Besides DTs, the other complications though uncomfortable, is seldom lethal in a healthy are seizures, , and hallucinosis. The amount individual. of medications needed to control withdrawal varies Good management requires an adequate knowl- greatly among patients. Although many - edge of the overall medical condition of the patient. drugs have been used to treat the with- Before withdrawal, medical conditions should be drawal syndrome, the long-acting , stabilized, including dehydration, infections, or and are currently the trauma that requires treatment. most widely used.62 These benzodiazepines have

76 Alcohol and Drug Abuse and Dependence the advantage of being cross-tolerant with alcohol, should be added to the . and their long half life is usually an advantage. is often used for this purpose, but care should be Model detoxification procedures are described in taken to prevent extrapyramidal syndromes in- Exhibit 5–2.63,64 cluding neuroleptic malignant syndrome. The usual detoxification procedure calls for the administration of adequate doses of benzodiaz- Abstinence Syndromes epines. For mild to moderate withdrawal, the pa- tient is initially given 50 to 100 mg of Abstinence syndromes include acute alcohol chlordiazepoxide or 5 to 10 mg of diazepam by withdrawal described above and other symptoms mouth or intravenously. Close observation with that can be protracted. These chronic symptoms attention to the signs of withdrawal and subjective point to a persistent hyperadrenergic state that may complaints guide the use of additional medica- last 6 to 12 months. Persistent insomnia, anxiety, tions.36 Objective findings to monitor are sweating, and depression can contribute to the risk of relapse hyperreflexia, tachycardia, confusion, agitation, by tempting the patient to seek relief with alcohol. body temperature, and blood pressure. A flow sheet Electrophysiological evidence for the existence of monitoring the patient’s condition and medications protracted abstinence in detoxified alcoholics has given greatly aids in management. The Clinical been demonstrated.39 Alcohol consumption by an Institute Withdrawal Assessment for Alcohol abstinent alcoholic may elicit withdrawal-like symp- (CIWA–A) is a reliable instrument that is available toms because of persistent latent central nervous to assess the severity of alcohol withdrawal.65,66 system hyperexcitability. In some alcoholics with Withdrawal symptoms are rated, and the scores are persistent hyperadrenergic states, helpful in titrating medications. Healthcare work- have proved useful.67 ers can be easily taught this scale to assess symptomatology and to monitor progress. How- Drug Abuse ever, the clinical evaluation still takes precedence over any test or scale in the final analysis of the Abusers of illegal substances are not tolerated in treatment. the military and therefore are less often the subjects Following the adequate administration of the of treatment. However, the military drug and alco- benzodiazepine during the first day or two, subse- hol clinics do provide outpatient treatment to the quent doses can be reduced rapidly because of the lower enlisted personnel for those who abuse sub- long half life of the drug. Uncomplicated detoxifica- stances other than alcohol. Senior enlisted person- tion is usually accomplished in 3 to 6 days. nel and officers are often processed for separation The most severe type of withdrawal, DTs, re- because they have undermined a public trust. quires the closest medical attention. In these cases, Withdrawal from and cocaine usu- diazepam intravenously is often used; 10 mg may ally causes some physical distress but is self-lim- be given initially, followed by 5 mg every 5 minutes ited. Life-threatening events are usually associated until a calming effect is achieved. Because diazepam with use including fatal arrhythmias, seizures, and and its major active metabolite have very long half cerebrovascular accidents. A drug-free environment, lives (about 36 hours), additional medication may symptomatic treatment, and psychological support not be required. Persistent hallucinations, , are usually sufficient. However, suicidal depres- and agitation may require neuroleptics. sions and paranoid psychosis may be manifested or The absorption of diazepam in intramuscular emerge on withdrawal, requiring vigorous psychi- form is quite unreliable, and therefore, patients atric care. Because of the usual severe underlying should be given oral diazepam or chlordiazepoxide social and personality disorders encountered in as soon as they are able to tolerate oral medications. drug abusers, treatment is necessarily complex and Combined treatment involving a benzodiazepine prolonged. A narcotic withdrawal procedure is and a sympathetic blocking agent, such as , described in Exhibit 5–3. The withdrawal from is emerging as a means of enhancing the effects of sedatives and hypnotics is very similar to that the standard benzodiazepine therapy of alcohol from alcohol, and the same procedure is applied withdrawal.29 Clonidine alleviates the hyperadren- with some modification. Exhibit 5–4 describes ergic state but does not protect against seizures. the procedure. are not indicated for the treat- Withdrawal from cannabis (marijuana, hashish) ment of withdrawal unless hallucinations, delu- is usually uncomplicated, requiring no medical in- sions, or severe agitation persist, in which case they tervention. Similarly “coming down” from a hallu-

77 Military Psychiatry: Preparing in Peace for War

EXHIBIT 5–2 MODEL ALCOHOL WITHDRAWAL PROCEDURE

I. Purpose: To prevent medical and withdrawal necessary. If IM benzodiazepines are needed, complications such as , use (Ativan). vitamin deficiency, neuropathic and 1. Diazepam (Valium): Initial loading dose encephalopathic disease, and aggravation of ex- of 5 to 20 mg P.O. every 1 hour until isting medical problems. Withdrawal symptoms symptom-free and mildly sedated. Usu- can begin within hours of the last drink but may ally 1 to 3 doses over 6 hours are needed not emerge until up to 7 days. but may require up to 12 doses over 48 II. Medications: All medications, if possible, should hours. Determination of the need for con- be given orally to avoid activating psychologi- tinue dosing should be made 45 minutes cal needs and symbolism of injections. Doses are after the previous dose. After symptoms based on the average (70 kg) person. Higher or are controlled, no more is needed be- lower amounts should be based on actual physi- cause of its long half life. cal status. 2. Chlordiazepoxide (Librium): Similar to A. Vitamins: Initially it is important to start the diazepam but scheduled especially if less debilitated patient on parental vitamins (ie, sedation is desirable. Doses of 50 to 100 thiamine HCL,1 Berocca parental nutrition) mg every 1 to 1.5 hours. immediately on admission to avoid the pos- 3. Lorazepam (Ativan): 2 to 4 mg IM as sibility of one of the permanent organic brain above if oral medication cannot be toler- syndromes or peripheral neuropathies. How- ated or IM medication is required. 1 mg ever, if oral intake is adequate, high doses of of lorazepam is equivalent to about 5 mg oral vitamins should be used for the first of diazepam. week. After than, an adequate diet should suffice. 4. Haloperidol (Haldol): 2 to 5 mg oral or IM every 4 hours or more often for per- 1. Berocca parental: 4 ml intramuscular (IM) sistent psychosis. (for 1 or 2 doses). 5. Diphenhydramine (Benadryl): 25 to 50 2. Vitamin K: 5 to 10 mg IM (for 1 or 2 times mg IM STAT2 for EPS,3 followed by any if prothrombin time is prolonged more oral anti-Parkinsonian agent if major tran- than 3 seconds beyond the control). quilizer is utilized and EPS develops. 3. Thiamine HCL: 100 mg IM. Start P.O. 6. Other major and minor tranquilizers can vitamins as soon as possible. be used depending on clinical experience. 4. Ascorbic acid: 500 mg per day. C. Sleeping medications: Should be avoided. 5. Pyridoxine HCL: 100 mg per day. Additional diazepam may be given in some cases. 6. Folic acid: 1 to 5 mg per day x 5 days. D. Anticonvulsive medications: Should not be 7. Multiple vitamins: 1 twice per day. used routinely but used only if seizures have 8. Thiamine: 100 mg 3 times per day. been a factor in the past. If a severe with- drawal has resulted in -like activity B. Tranquilizers: Type should be based on sev- despite diazepam use, the following can be eral factors of which physician’s experience, used for 7 to 10 days: drug, and patient characteristics are of para- mount importance. These can be used dur- 1. Phenytoin (Dilantin): 200 mg IM, then: ing the first few days of detoxification if 2. Phenytoin: 100 mg, 4 times per day P.O. needed. Care should be taken not to overuse Do not exceed blood levels of 1 to 2 mg/ tranquilizers or other sedatives in the acute dl therapeutic range. intoxication phase or with markedly elevated alcohol blood levels (eg, 100 to 150 mg/dl or 3. Note that even with IM dosing, thera- above). Benzodiazepines are the drugs of peutic levels usually take several days. choice, but major tranquilizers can be used if

78 Alcohol and Drug Abuse and Dependence

EXHIBIT 5–2 (continued) MODEL ALCOHOL WITHDRAWAL PROCEDURE

E. Antihypertensives: Elevated blood pressure postprandial blood sugar, sputum for cul- is common in alcohol withdrawal and may ture, and sensitivity. revert to normal after detoxification. Aldomet, beta-blockers, and calcium chan- IV. Nursing Care: nel blockers may be used for dangerous A. Vital signs: elevations. 1. TPR9 and blood pressure four times per F. Intravenous fluids: Only if severe dehydra- day for 3 days, then routine. Pulse and tion, orthostatic hypotension, hemoconcen- blood pressure, supine then after 3 min- tration, vomiting, or debilitation. The rapid utes standing, for 48 hours, then routine. administration of 1 to 2 liters of balanced intravenous fluids with vitamins added, in- 2. Weight: Admission and then 2 or 3 times fused over several hours should reduce per week. morbidity. B. Diet: Initially patients may need assistance, III. Laboratory Tests: encouragement, and direction in obtaining an adequate diet. A. Within 24 hours or sooner: Initial blood alco- hol, blood sugar, CBC4 (to include mean blood 1. Fluids: Large oral intake is necessary be- cell volume, MCV5), urine analysis, (includ- cause of various degrees of dehydration. ing drug screen), liver screen (at least SGOT,6 Orange juice is a good source of potas- SGPT,7 LDH,8 alkaline phosphatase, biliru- sium. Supplemental magnesium may be bin, albumin), serology, chest X-ray (poste- needed. rior, anterior, and lateral). A MCV increase 2. Supplementary feedings, if indicated. may indicate folate deficiency, liver disease, or reticulocytosis. C. Orientation: Patients should be oriented and familiarized to the unit. Orientation and men- B. Blood antibodies for human immunodefi- tal status should be checked and noted daily. ciency virus (HIV). C. Electoencephalogram and electrocardiogram should be done initially only if clinically 1. HCL—hydrochloride indicated and are best repeated after 7 to 10 2. STAT—immediate days of return to a fairly normal physiologi- 3. EPS—extrapyramidal symptoms 4. CBC—complete blood count cal status. 5. MCV—mean corpsular volume D. Other tests to consider: electrolytes (sodium, 6. SGOT—serum glutamic oxaloacetic transaminase potassium, chloride), blood urea nitrogen, 7. SGPT—serum glutamic pyruvic transaminase creatinine, amylase, bromsulphthalein (for 8. LDH—lactic dehydrogenase 9. TPR—temperature, pulse rate, respiratory rate hepatocellular damage), fasting and 2-hour

cinogen “trip” usually requires a knowledgeable his last drink 3 days ago. This service member presented person to “talk down” the patient and prevent him a history of drinking the past 18 years. He had previously from coming to harm. Phencyclidine and atropine- experienced blackouts or periods of after drink- like poisoning may require more intensive medical ing. He was hospitalized twice in the last 10 years for alcohol withdrawal symptoms when he was unable to intervention. obtain alcohol during field exercises. Following the last withdrawal episode 6 months ago, he was placed in the Case Study 4 RTF and was recently returned to duty with follow-up treatment at his local ADAPCP. He discontinued disulfiram A 34-year-old serviceman with 14 years of active duty a month ago and started to drink because of work stress. was brought to the station hospital because he seemed On admission, he was placed on the alcohol detoxifica- “keyed-up” and restless on duty. He claimed to have had tion protocol because he was grossly tremulous and

79 Military Psychiatry: Preparing in Peace for War

EXHIBIT 5–3 EXHIBIT 5–4 MODEL SPECIFIC SEDATIVE/HYPNOTIC MODEL NARCOTIC WITHDRAWAL WITHDRAWAL PROCEDURE PROCEDURES

Generally, most of the alcohol standing operat- Procedure is the same as for alcohol, except ing procedure applies. administer additional medications to control physi- cal symptoms. 1. Tranquilizer withdrawal: For oral drugs use diazepam. If IM needed, use lorazepam; 1 mg 1. Narcotic withdrawal: A narcotic antagonist lorazepam equals 5 mg diazepam. will start the withdrawal abruptly or reverse an acute overdose. and clonidine a. Loading dose: 10 to 20 mg diazepam or 2 can be used to prevent withdrawal symp- to 5 mg lorazepam IM. toms although withdrawal by itself is not life- b. Maintenance dose: Repeat dose every hour threatening. over next 6 to 48 hours until symptom- a. Acute overdose: Naloxone 0.4 mg IM, in- free and mildly sedated. Determine next travenously or subcutaneously every 5 dose after 45 minutes of previous dose. minutes until awake. Usually 2 to 3 vials Once stability is achieved, no further are adequate. Note that the short half life diazepam is needed because of its long of naloxone requires repeated dosing. half life. b. Initiate withdrawal dose: As above but 2. Barbiturate withdrawal: Check for level of less frequent to produce physical with- tolerance with use of short-acting drug. There- drawal symptoms. after, a long-acting drug can be used for with- drawal. c. Methadone dose: This long-acting nar- cotic can be used for withdrawal. a. Test dose: Pentobarbital. 50 to 200 mg P.O. every 1/2 to 1 hour over 6-hour pe- (1) Initial dose: 15 to 20 mg P.O. riod to point of intoxication: , nys- (2) Withdrawal dose: Repeat dose when tagmus, slurred speech. If less than 100 to symptoms return over 24 hours. Re- 200 mg produces intoxication, then a duce daily dose by 5 to 10 mg per day. detoxification schedule is not needed. b. Stabilization dose: the 6-hour test dose is given 4 times per day for the next 1 to 3 days. 30 mg can be substi- tuted for 100 mg pentobarbital and given and recurrent drinking, he was administratively separated once or twice per day because of its long from the service. half life. Comment: This is not the typical outcome of those soldiers enrolled in the RTF. The great majority of them are c. Withdrawal dose: Decrease 100 mg motivated for treatment and respond positively with a suc- pentobarb or 30 mg phenobarb, or less, cessful completion of the program (eg, Case Study 3). per day over the next 10 to 20 days. If However, there are individuals that are unable or unwilling withdrawal symptoms occur, reduce dose to break through the denial and to confront their disorder. more slowly. Consider blood and urine Thus, they end up as treatment failures with their conse- for barb levels and other drugs. quences. Because there are no means to clearly predict the patient’s response to treatment before admission to an RTF, the first 2 weeks as an inpatient are critical in terms of assessing the potentials for treatment and outcome. Here, diaphoretic. Over the next few hours, he became increas- commanders are involved in the decision of continuing ingly confused, agitated, and aggressive. He displayed treatment or not. In most cases, a failure in treatment in the disorientation for time and place, felt that he was in prison, RTF, like a failure of outpatient treatment, leads to an and saw “bugs” around the bed. He also felt that he was administrative separation from the service. being poisoned. He loudly insisted that he was innocent and wished to leave. Following a week of hospitalization Case Study 5 during which time large doses of benzodiazepine were administered along with haloperidol to treat his delirium, A 28–year-old serviceman with 10 years of active duty he recovered from the episode with spotty recollection of was referred to the base medical treatment facility when the events. Because of his poor compliance to treatment his commander noted irritability and an alcoholic breath.

80 Alcohol and Drug Abuse and Dependence

Examination indicated the soldier to be intoxicated with a Medications were given, and his condition was monitored BAC of 0.10 mg% of alcohol and mild incoordination. He for the next few days. He recovered uneventfully. On the presented a history of drinking since he entered the Army recommendation of the medical officer, he was enrolled in at age 18. He had arrived overseas 2 months previously. the RTF (Track III) by his commander because he had Six years ago, he completed the outpatient program been a “good performer” until recently. He complied with following a drinking while intoxicated incident. Knowing the program requirements, elected to take disulfiram, and from past experiences that he had a tendency to lose appropriately confronted his long-standing substance dis- control of his drinking, he generally refrained from alcohol order. He regularly attended the AA meetings and dis- use until he arrived overseas. On arrival here, his unstable played a definite motivation toward rehabilitation. On marital relationship collapsed, and he also experienced the successful completion of the inpatient phase, he significant job stresses. He succumbed to peer influences returned to duty and continued treatment as an outpatient. as in the past, and soon he was consuming alcohol several Follow-up 8 months later indicated that the soldier was times a week. He unsuccessfully attempted to decrease his doing well on duty and had remained abstinent. drinking. Recently, he had experienced blackouts. Comment: Some soldiers with 8 to 15 years of active The service member was placed under observation. service turn to alcohol or drugs in the midst of personal or Over the following 24 hours he became increasingly career crises. The above case exemplifies the tremulous and agitated. He also displayed tachycardia, commander’s concern for his soldier and the therapist’s sweating, mild blood pressure elevation, and nausea. attentiveness to the patient’s life circumstances.

TREATMENT MODALITIES

Counseling largely depend on for his continued recovery. Its basic beliefs are embodied in the well-known 12 Therapeutic groups and group therapy are the steps.69 principal treatment modalities for alcoholism. Indi- The AA program is a spiritual way of life without vidual counseling is of limited use in a disease that any creed or dogma. It is compatible with any pro- is best treated by peer group support and group gram of recovery and is a vital adjunct to the man- counseling.68 When individual sessions are used, it agement of alcoholism. AA has always viewed alco- is to provide the initial support, confrontation, ven- holism as a disease and has considered abstinence tilation, and resolution of the immediate crisis. These as the only realistic goal. It teaches its members to sessions are basically used to prepare the individual resist the strong internal and external pressures to for group counseling and AA. In both types of coun- drink by living one day at a time. For many years seling, the here-and-now approach is utilized with the before the establishment of any military treatment focus on abstinence. Exploration as to reasons for program, AA was the only source of “treatment” drinking are avoided. The counseling is done in a available. Soldiers who were motivated and who supportive confrontational manner, especially in deal- participated seemed to obtain the help that they ing with the strong denial of the patients. sought. The peer group provides the extremely neces- Alcoholism is a lifelong disorder; therefore, for sary support and a system of dealing with anxiety, continued support and recovery, the individual isolation, loneliness, anger, and rejections. These should become dependent on the AA program rather therapeutic groups serve as a place for patients to than any particular individual or agent. AA groups learn about alcoholism, benefit from fellow pa- provide hope, a social network to remain abstinent, tients in different stages of recovery, and obtain help a crisis response system, and a worldwide organi- from members for specific problems. zation with many members and local branches. For many, the missing of AA meetings usually leads to Alcoholics Anonymous and Other Self-Help a relapse. Groups Conceptualized in a similar manner, NA is cur- rently available for those that abuse or are depen- Founded more than 50 years ago by two men dent on other substances. Al-Anon and Alateen seeking a means to remain abstinent, AA has con- work in conjunction with AA to assist family mem- tinued to be the most potent of all resources to help bers of those with alcoholism to help themselves those with alcoholism. It is considered a bona fide and their addicted member by providing educa- treatment modality by the military and is used tion, support, and needed interventions. A rela- extensively by both outpatient and inpatient pro- tively new organization, Adult Children of Alco- grams. AA is the organization that a soldier must holics (ACOA), is helpful for those whose parents

81 Military Psychiatry: Preparing in Peace for War had alcoholism. For those who are atheists or who need to be instructed on the foods and products eschew a dependent role, a new organization based containing alcohol. Medication in elixir form should on Ellis’ Rational Emotive Therapy and cognitive be avoided unless it specifically is labelled nonalco- therapy is emerging. These groups supply peer holic. Sensitive persons may react to aftershave support similar to AA. lotion, mouthwashes, or external agents containing alcohol usually through inhalation. Because Disulfiram disulfiram accumulates in the body, patients may have some reaction to alcohol up to 2 to 3 weeks No medication by itself should be considered the after the last dosage if they resume drinking. Be- treatment for alcoholism. There are medications, cause some complain of drowsiness after taking however, that can serve as adjuncts to treatment. disulfiram, the dosage can be taken before sleep Disulfiram (Antabuse) is one that is used exten- rather than during the day. Other minor complaints sively in the recovery programs of both outpatients are of a metallic or garlic taste in the mouth and and inpatients with good success.70 In military treat- mild indigestion. The former disappears in a week ment centers, although encouraged, it is not made a or so, and the latter can be controlled by taking requirement. It is only prescribed with the patients’s disulfiram with food. For those allergic to disulfiram, full knowledge and consent. Offered to help one metronidazole (Flagyl) is an alternative medication resist the impulse to drink, it is compatible with that also blocks aldehyde dehydrogenase. other forms of alcoholism treatment. Although short- Metronidazole and disulfiram should not be taken term use of disulfiram should be the intent while together. the person solidifies his recovery program, this medication has been used for 1 year or more in those Psychiatric Comorbidity that have required this support. Disulfiram should not be used in those with A variety of clinically significant psychiatric dis- significant liver disease or those that are unable to orders can coexist with alcohol dependence. These stop the use of alcohol. Other methods should be disorders confer a poorer prognosis in treatment utilized to encourage abstinence. Before prescrib- and modification of treatment with additional ing disulfiram, the physician should review its pre- psychotherapeutic approaches, and pharmacologic cautions, contraindications, and drug interactions. agents may be necessary. To diagnose and treat Disulfiram works by blocking the enzyme alde- these disorders, it is essential that these soldiers are hyde dehydrogenase, which is necessary for the also seen at the local mental health facility or by the breakdown of acetaldehyde. On ingestion, alcohol division psychiatrist. Depression is the most com- is metabolized in the liver to acetaldehyde. mon associated among those with Disulfiram causes the accumulation of acetalde- alcoholism. Depressive symptoms commonly seen hyde, which produces the “alcohol-Antabuse reac- in alcohol withdrawal frequently remit spontane- tion.” This reaction is manifested by nausea, flush- ously with time. For depression that persists be- ing, dysphoria, dyspnea, hypertension, headache, yond the period of acute withdrawal, a tricyclic and sometimes emesis and syncope. In rare in- or heterocyclic antidepressant is the stances in which the individual has cardiovascular usual drug of choice. These medications are usually or cerebrovascular disease, heart failure, stroke, appropriate for chronic anxiety and panic attacks of and death are possible. Very rarely disulfiram may the hyperadrenergic state also. produce an acute brain syndrome mimicking in- Because comorbid disorders contribute to the toxication. This occurs in about one in 1,000 patients deficient behavior and functioning of one with alco- and usually on higher doses (500 mg).70 It is fully holism, the treatment of concomitant pathology is reversible with discontinuance of disulfiram. Care- essential. Psychotropic medications may be indi- ful monitoring of patients on disulfiram is essential cated to treat the negative states that contribute to because it is not an innocuous drug. relapse.38 These medications include antidepres- Patients starting disulfiram need to be free of sants, lithium, antipsychotics, and antianxiety alcohol for at least 1 full day. The usual procedure agents. It is necessary to assess the response and is to prescribe a loading dose of 500 mg for a few continued indications in follow-up. The days and then a daily maintenance dose of 250 mg. antianxiety agent of choice is because Because taking alcohol in any form may cause a it is not addictive and does not increase alcohol reaction, before starting this medication, patients brain depression.

82 Alcohol and Drug Abuse and Dependence

PREVENTION AND CONTROL

Current Data possible, but also to serve as a deterrent to the use of substances by troops. The techniques of biochemi- The efforts since 1971 in decreasing substance abuse cal analysis as well as the administrative proce- among military personnel have resulted in significant 18 dures in running a secure testing program have gains in the 1980s. Worldwide studies during the been significantly refined to minimize false-posi- past 10 years have indicated a general decline in both tives. A urine positive rate up to 2% has been con- drug and alcohol use. However, the reduction in drug sidered acceptable within the troop population as use has been much more substantial than has alcohol 17 evidence of adequate surveillance and control. A reduction. “Drug use among military personnel de- rate higher than this would be of some concern as to clined dramatically between 1980 and 1988 and is now the adequacy of control measures. Identification of the lowest since the survey series began. The declines drug abusers as early as possible is considered impor- are probably partially related to similar declines among tant to not only restrain their own drug use, but to civilians, but they also demonstrate the continuing curtail the spread of drug use to others in the unit.72 effectiveness of military efforts to eliminate drug use 26(pxix) Only results reported from the large certified among military personnel.” laboratories can be counted on as legal evidence; Although the abuse of psychoactive drugs may any testing done in the field is still considered have been significantly curtailed by the current 26 inaccurate. For purposes of assessment and treat- military preventive and control measures, alco- ment, these field test results may be useful but hol, by its availability and widespread use, contin- not beyond that. Likewise, breathalyzers are very ues to create a problem among its users. “In 1988, useful in the field for the determination of alco- about 83 percent of military personnel were current hol in the blood, but their use is limited to medi- drinkers, with about two thirds being moderate to cal management. Recently, drug testing has in- heavy drinkers and 8.2 percent being heavy 26(p13) cluded cannabis, cocaine, phencyclidine (PCP), drinkers.” “Drinking levels are positively re- opiates, and amphetamines where use of these lated to serious consequences. Heavy drinkers ex- 26(p35) substances is suspected. The presence of perience the most consequences.” medicinals, such as opiates and amphetamines, Recent epidemiological studies indicate an in- on urine drug screens create special problems; creasing consumption of alcohol in the general popu- therefore, written procedures are available to the lation, and the prevalence of alcoholism seems to be physician (medical review officer) in evaluating increasing as well. In those that are susceptible, the these cases. risk of alcoholism is greater, with the age of onset being earlier than in the past.28 This phenomenon Education would impact on the military services in a signifi- cant manner because the bulk of the service mem- In any preventive program, education remains bers are young people. the key, and this cannot be overemphasized in the In the military services, current alcohol and drug area of substance abuse. Disciplinary action and use seems to be concentrated among the younger, treatment are means of dealing with abusers of less-educated, unmarried, junior and midcareer substances, but primary prevention depends on the enlisted personnel.71 It has also been noted that educational efforts promoted by command. A vari- “alcohol-related serious consequences, productiv- ety of means are available to command to do this. ity loss, and alcohol dependence are substantially Alcohol and drug preventive educational sessions higher among E1 to E3 pay grades; for any negative are usually included during annual training with effects and alcohol dependence, rates for E1 to E3s are support from the installation Alcohol and Drug almost twice as high as E4s to E6s and for productivity Counseling Center. loss, about 10 percentage points higher.”26(p33) It seems essential that the current programs be continued to Deglamorization of Alcohol maintain the gains of recent years. Deglamorization appears to have done its part Biochemical Testing in the reduction of alcohol use and abuse in recent years. Military social activities no longer Random urinalysis for substances has been im- emphasize drinking, and even penalties are portant not only to identify abusers as early as awarded in situations in which drinking is

83 Military Psychiatry: Preparing in Peace for War promoted. The health promotion efforts of the ing involved in some administrative action, ap- DoD definitely seem to have a positive impact on pears to serve as a positive deterrent. Because the current attitude toward alcohol and drug use prevention and control are a command responsi- not only in the workplace, but also at all other bility, commanders should be familiar with the times. administrative and medical resources at hand to In addition, the driving while intoxicated pro- accomplish the mission of maintaining the unit’s gram, with commanders being notified and be- health and readiness.

OPERATIONAL CONSIDERATIONS

The Combat Medical Provider’s Tasks ment of the alcoholic or drug-dependent soldier during wartime, regardless of the difficulty in de- Substance abuse disorders have a special interest tection. In the midst of interference created by in- to military medicine and, in particular, to those in creased consumption of alcohol and adventitious the combat environment. The unique problem for use of illicit substances, how can the clinician im- the combat care provider is that while he can expect prove his ability to identify the patient who should to deal with the consequences of abuse, he must receive a definitive rehabilitation for a substance improvise a solution without the familiar structure dependence disorder? The answer—he must em- of the employee assistance model that is commonly phasize command consultation with the goal of available throughout the DoD in peacetime. Given encouraging the primary prevention of substance the elevated base rates for substance misuse under use through command policies that deglamorize conditions of excessive combat stress, before reach- excessive alcohol consumption and assist abstinence ing a diagnosis of substance dependence, he must from illicit drugs through detection and adminis- guard his index of suspicion by avoiding criteria trative sanctions (to include judicial avenues). based on amounts consumed. The problem is that Recognizing that the exaggerated consumption the threshold of abuse (as defined chiefly by con- he observes is symptomatic of the stressful environ- sumption level) may rise above the norms to which ment, he may assist the commander to lower the the clinician is accustomed. Moreover, his clinical stress by facilitating increased cohesion, communi- objectives are defined by the short-term focus of cation, and group support to dissipate some of the manpower conservation to return the patient to excess tension. Finally, he can make the commander duty, rather than the long-term goal of occupational aware that he may have the strongest influence over rehabilitation. His immediate concerns are detoxi- excessive consumption because key factors to ex- fication and observation for acute withdrawal cessive use are social pressure to drink and inex- syndromes, with less attention given to the pensive alcoholic beverages. In fact, social pressure soldier’s rehabilitation. and inexpensive access may explain two-thirds of Three predictions appear likely: first, the combat the difference between various occupational groups clinician will treat an increased number of overuse considered at high risk for drinking problems.20 cases than he would typically encounter in peace- time practice; second, there will be no greater inci- Setting The Stage For Rehabilitation dence of substance dependence disorders than nor- mally occurs (3 to 5% in the military population);26 In a combat environment, the clinician should and third, dependence disorders will be more diffi- not anticipate that he will have the luxury of send- cult to confirm because of increased consumption ing many (if any) with chronic alcoholism away for and the pressures to return expeditiously as many rehabilitation. Most of his efficacy must be directed patients as possible to duty. That is, the sensitivity toward the acute condition and his clinical role in and specificity of his clinical decisions will be mark- setting the stage for later definitive treatment. He edly affected by the aberrant consumption patterns can do this in several ways. First, he can provide the of wartime. patient with an unequivocal diagnosis of substance abuse when the facts support it. Not uncommonly, Limiting Interference a patient has been released after detoxification with- out a frank discussion between doctor and patient This presents the greatest clinical dilemma: it is about his alcoholism. The cofounder of the Navy’s no less important to obtain correct and timely treat- rehabilitation system received no less than seven

84 Alcohol and Drug Abuse and Dependence postretirement hospitalizations before anyone men- ment all the facts as they are revealed in the history tioned the connection between the detoxification so that future providers can follow a trend. This sets and substance abuse.73,74 In addition, one must docu- the stage for later intervention.

SUMMARY AND CONCLUSION

Among newly inducted young service members, ranks with intensive programs of prevention, con- there usually is an increased use of a substance, trol, and treatment, have been rewarded with al- namely alcohol, in the new military setting. This most a total eradication of illegal drug use and a may be to alleviate the anxiety of being in a stressful decreasing alcohol consumption. The command- situation as well as exercising the new found free- centered substance abuse program with support dom away from home. In addition, illicit drug use from the medical services has been highly success- that may be associated with alcohol use can emerge. ful. The continued success of the substance abuse Because the experiment with Prohibition was a program will depend on the viability of the existing failure, alcohol will always be with us. Thus, there structure and relationship with command. will always be service members who will develop Whether in peace or in war, substance abuse is a abuse and dependence disorders. Likewise, drugs problem that requires monitoring and surveillance. of whatever nature, such as cannabis, phencyclidine, In addition, substance abuse cannot be separated cocaine, amphetamines, opiates, or designer drugs, into a command or a medical problem. Because the will periodically emerge to threaten and undermine emergence and the maintenance of substance abuse the health and readiness of troops. are multidetermined, like any behavior, the man- Since 1971, the military services, with their re- agement and disposition are highly complex and solve to deal with substance abuse among their require both administrative and medical elements.

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